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A Rapid Resolution and Redress scheme was one of the key recommendations coming out of the Better Births report. This month the Department of Health has launched a consultation on this proposal.

Currently families whose children have suffered severe injury due to negligent maternity care have to wait an average of 11.5 agonising years to receive compensation. A Rapid Resolution and Redress scheme should offer a shorter, more supportive option for parents.

Birthrights will be responding and will be publishing a guide to the proposals on our website in the next few weeks. If you have direct experience we would particularly urge you to respond to this consultation and use this opportunity to have your voice heard.

Following the recent NMC decision on the indemnity cover that IMUK members have taken out, Birthrights has been working to support women who now find themselves without the midwife of their choosing. I wanted to give you an update on what we have been doing to help and to respond to some requests for information.

Letter to the NMC
As you may know, I wrote to the NMC’s Chief Executive, Jackie Smith, as soon as the decision was made public to express my concerns and ask for clarification. I have now received a response from Ms Smith and am asking the NMC to allow me to make that response public. I hope to share it with you in due course.

In my letters I am making it clear that NHS Trusts (and Head of Midwifery post-holders as Trust employees) are under a legal obligation to facilitate women’s right to make choices about birth (Human Rights Act and Article 8, European Convention on Human Rights). In order to discharge their obligations lawfully, they must diligently consider all the mechanisms in their power to enable women’s choices and decisions in childbirth to be respected. I am informing them that they must consider the individual circumstances of the woman and her particular situation rather than invoking a blanket policy, and insisting that when the Trust has made a decision it must give its full reasons for their decision and these reasons must be clearly justified.

Given that some Trusts have swiftly been able to arrange honorary and/or bank contracts with local independent midwives in this situation, it is not clear what justification other Trusts have for refusing to grant a similar arrangement. So, I am asking them to consider their legal obligations carefully, to investigate how other Trusts have been able to accommodate independent midwives and to reconsider the options available.

I have also included some information about the likelihood of some women feeling forced to freebirth, particularly in the absence of any equivalent provision for continuity of carer within the local NHS services. And I have expressed an urgent concern about the avoidable harm that could come to women and babies in this situation, as well as the difficult position that Trust staff could find themselves in should a disengaged and fearful woman need to access emergency care in labour or the broader perinatal period.

In these circumstances, the granting of honorary or bank contracts may represent the only way for vulnerable women to access any maternity care at a critical time in their pregnancies.

Concerns about midwives attending the births of friends and familyThere has been recent publicity, linked to the independent midwives’ situation, concerning the legal position for all midwives attending a close friend or family member in the intrapartum or broader perinatal period.I am aware that, until now, it has been perfectly routine and accepted practice for midwives to attend their close friends and family members in labour, both in a supporter role and as a practicing midwife.However, Birthrights is not in a position to give legal advice to those seeking clarity on the current legal position on this matter. We suggest that midwives contact the RCM, the NMC and speak to their NHS Trust to get clarification on the situation in their area and their particular circumstances.

We will continue to do all we can in public and behind the scenes to support women and their midwives at this challenging time.

Birthrights strongly criticised today a decision by the Nursing and Midwifery Council (NMC) that prevents many independent midwives from caring for women in labour. The decision (which relates to the level of indemnity insurance arranged for many independent midwives by their umbrella body, IMUK) has resulted in the regulator instructing pregnant women to make immediate alternative arrangements for their birth care.

In an urgent letter to NMC chief executive Jackie Smith, Birthrights CEO Rebecca Schiller said that the NMC’s actions, “appear designed to cause maximum disruption and damage to independent midwives and the women they care for,” adding that, “we do not believe that these are the actions of a responsible regulator.”

Schiller adds that “the NMC has a key role to play in protecting public safety, yet this decision directly jeopardises the health and safety of the women it is supposed to safeguard. Beyond the very real physical health implications of this decision, it is causing emotional trauma to women and their families at an intensely vulnerable time. To date, it appears that the NMC has shown no concern for the physical and mental wellbeing of pregnant women who have booked with independent midwives.”

In the letter, Birthrights highlights the unnecessarily tight timescale imposed by the NMC and lack of attempt to communicate what constitutes adequate levels of insurance. Schiller expresses her concern that some women will now feel forced to give birth alone adding, “many women choose the care of an independent midwife because they are unwilling to access NHS services, often because of previous traumatic experiences. Without the support of their chosen independent midwife, women have already told us that they feel their only option will be to birth without any medical or midwifery assistance. We hope that you will share our urgent concern about the avoidable harm that could come to women and babies in this situation.”

Birthrights is urging the NMC to remedy the damage caused to date by taking urgent steps that include:

Guaranteeing that all women who are currently booked with independent midwives using the IMUK insurance scheme will be able to continue to access their services

Reassuring Birthrights, IMUK and the women who have already engaged the services of independent midwives that the midwives caring for them them will not face disciplinary action for fulfilling their midwifery role

Urgently making a public recommendation on what constitutes adequate insurance.

The Grand Chamber of the European Court gave judgment today in Dubska v Czech Republic. We wrote about the earlier decision of Court here. The Court reaffirmed that women’s rights in childbirth are protected by Article 8 of the European Convention on Human Rights, further underlining the human rights protections that childbearing women should enjoy.

But in a disappointing and poorly reasoned judgment, the Court found that the Czech government was not obliged to regulate midwives to enable them to attend women at home births, despite the significant negative impact this may have on the safety and wellbeing of childbearing women. The Court accepted that care in Czech maternity hospitals was ‘questionable’ and expected the Czech government to keep its law and practice under “constant review so as to ensure that they reflect medical and scientific developments whilst fully respecting women’s rights in the field of reproductive health”.

Five of the judges dissented, expressing a joint opinion that disagrees with the Grand Chamber’s judgment. These judges found that the Czech system effectively forces women to give birth in hospital and could not be justified by any public health argument. They noted the observations of the CEDAW Committee on disrespectful and abusive practices in Czech hospitals. As they said, citing the UK Supreme Court’s decision in the Montgomery case, ‘Patronising attitudes among health personnel should not be taken lightly, as they may constitute a violation of an individual’s right to self-determination under the Convention.’

This judgment is a missed opportunity to offer appropriate, safe and rights-respecting choices to Czech women. Women giving birth in obstetric units in the Czech Republic face a range of unsafe and rights-violating practices, meaning that for some choosing to birth at home is the only way of avoiding degrading, painful, lonely and de-humanised care. Routine practices in these units include: separation from their babies, a lack of access to facilities that support physiological birth, no involvement in decisions about their care, routine episiotomy, lack of pain-relief options, giving birth without a partner unless they pay an additional fee. Without regulated and state-supported access to out-of-hospital birth it is likely that some women will now feel forced to give birth without medical assistance. When hospital births that undermine a woman’s basic human dignity are the only option, there are significant safety issues at stake.

For women in England the judgment has no impact on their right to choose where to give birth. Choice of place of birth is enshrined in policy and practice, and underpinned by the recent report of the National Maternity Review. But for women in eastern Europe this will create a significant bend in the road that activists, mothers and health care professionals will need to navigate with clarity and purpose to minimise the damage.

Thankfully the clamour for childbirth rights, and a shared understanding of how to promote them, is growing across Europe. More cases on abuse during childbirth will undoubtedly reach the Court and other recent ECHR judgements (such as Konovalova v Russia) still stand; robustly upholding women’s rights to make decisions about childbirth.

Given the forceful dissent, and the Court’s demand that the government keep pace with change, this is unlikely to be the last word on homebirth in the Czech Republic.

Remarkably the key role that Supervisors of Midwives play in advocating for women doesn’t even get a mention in the consultation document. As an organisation we refer women to SoMs on a daily basis – they are crucial defenders of women’s human rights. Today we need to defend these defenders. That is why we have today submitted the response below to 3 key questions in the consultation. If you haven’t already – please join us in submitting a response…

Q1. Do you agree that this additional tier of regulation for midwives should be removed?

No. At Birthrights, we believe that safe maternity care is contingent on respectful care and that a human rights-based approach offers the best means of improving maternity services in the UK.

In the current regulatory system in the UK, Supervisors of Midwives (known as SoMs) play a dual role: they are responsible for making sure that midwives under their charge abide by professional standards and they are responsible for supporting and facilitating women’s decisions about their pregnancy and birth. SoMs provide a critical protection for women’s rights in maternity care. They enable women who may have been refused access to specific services to obtain the care they want and need; they negotiate with obstetricians and other members of the maternity team to support women’s choices; they are at the heart of planning safe and respectful care for more complex births. Birthrights calls on the help of SoMs for the women we advise on a daily basis. Remarkably, this aspect of SoM’s role does not appear in the consultation document. Birthrights is deeply concerned about the consequences of removing the role of SoMs without giving any proper thought to how to maintain this critical function.

We recognise that improvements must be made to the current regulatory system. Morecambe Bay showed what can happen if the statutory supervision system is not well understood, supported and implemented. A weak supervisory system can be subverted to protect midwives rather than to advocate for women. However, we believe that the response to the tragic failures at Morecambe Bay and elsewhere must put respect for women at its heart. Safety can only be achieved by full recognition of women’s right to dignity and respect in maternity care. This entails much more than compliance with protocols or improved documentation; it means genuinely personalised care given by staff who listen to women and respect their individual needs. This requires ongoing access for women to an “expert” who understands the care setting and can help women to navigate it. The role of SoM, protected by statute, provides a healthy level of challenge to Trusts to ensure they remain focused on women’s needs, and fulfil their obligations under the NMC Code and human rights law.

With the RCM, and others, we are concerned that putting supervision on a non-statutory basis will leave supervision at the mercy of employers to fund and implement. These changes move supervision from a must have to a nice to have. In the current financial climate of the NHS, that does not bode well. Indeed it could create many of the problems with supervision that were reported in Morecambe Bay where supervision was not prioritised, and where SoMs put their loyalty to their employer, and colleagues, above their loyalty to the Local Supervising Authority. Supervisors may be forced to tow the line of their employer or leave themselves exposed for standing up for women. Regulatory systems that fail to protect women also fail to protect midwives: Birthrights is aware of cases in other countries where midwives have faced criminal prosecution because they have supported women’s decisions to give birth in ways that are not supported by mainstream health providers. There is a real risk that eroding the distinctive system of regulation for midwives will leave women and midwives in a highly vulnerable position.

The proposal in the consultation document that supervision continues merely “as a vehicle for professional support and development” entirely fails to appreciate the distinctive role of SoMs in the provision of safe and respectful care for women. In their focus on the regulatory intricacies of supervision, the Department of Health and the NMC have overlooked this crucial aspect of safe care. They do so at the risk of endangering women and babies and degrading the quality of maternity services.

Birthrights calls for guaranteedaccess for women to SoMs who are explicitly charged with promoting respectful care and upholding the NMC Code.

Q2.Do you agree that the current requirement in the NMC’s legislation for a statutory Midwifery Committee should be removed?

Birthrights does not agree that the statutory Midwifery Committee should be removed.

Midwifery is a distinct profession from nursing. It is not based on a curative model of care, but on a social model, which has significant implications for the way it is both practised and regulated. Midwifery puts the needs of women and their families at its heart; its does not treat a specific complaint but supports a woman in her transition to motherhood. The NMC must ensure that the unique characteristics of midwifery are respected and protected and maintaining the Midwifery Committee is the means of achieving this.

Furthermore, modern regulation should understand and meet the needs of the community that it regulates. It is contrary to best regulatory practice to create super-regulators that are distant from the professionals they serve. The abolition of the midwifery committee will lead to the loss of midwifery standards and ethics in regulation; and the assumption of nursing standards will be detrimental to the distinctive practice of midwifery.

Q13:Do you think that any of the proposals would help achieve any of the following aims:

eliminating discrimination, harassment, victimisation and any other conduct that is prohibited by or under the Equality Act 2010?

advancing equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it?

fostering good relations between persons who share a relevant protected characteristic and persons who do not share it?

No. Birthrights is concerned that the elimination of statutory protection for the role of Supervisor of Midwives will have a detrimental impact on pregnant women. Currently, pregnant women have access to a SoM who supports and facilitates their healthcare decisions. This role reflects the unique position of pregnant women in healthcare services; for the majority, they are not receiving treatment for a condition, but seeking support for a normal life process which requires support and respect for their decisions. If pregnant women are no longer able to access SoMs, they will undoubtedly receive less support, the quality of their care will diminish and their safety will be compromised.

These proposals should be changed so that the role SoMs play in supporting women is given proper recognition. This may be by maintaining statutory supervision or by placing an enforceable obligation on Trusts to ensure that women are given guaranteed access for women to SoMs who are explicitly charged with promoting respectful care and upholding the NMC Code.

Speaking in advance of the release of the NHS England National Maternity Review report’s release today, Birthrights Director Rebecca Schiller said, “the National Maternity Review report has a powerful message for all interested in improving maternity care. Birthrights agrees with the Review team’s vision that safe maternity care is personalised care and welcomes the recommendation that women should be in control of their care through the introduction of personal maternity care budgets.In our August 2015 letter to the Review team we set out that safe maternity care is contingent on respectful care and that a rights-based approach offers the best means of improving maternity services in the UK.We are therefore delighted to see that innovations to support women’s autonomy have been included in the plans. We echo the insistence throughout the report that genuine choice and unbiased information should be supported by healthcare professionals and service infrastructure.

It is now crucial that these ideas become a reality. We believe that the human rights legal framework and the values it promotes are vital tools in seeing this vision come to life.Many of the report’s recommendations are supported by rights women should already enjoy. These rights arise from human rights law and existing policy and could provide a strong platform from which to demand that changes are made. The report’s ambition that all women are offered choice of place of birth by 2020 is a reality women should already expect, based on long-standing Department of Health policy which stipulates that women should be able to choose where to give birth. It is time for action to match rhetoric.”

Elizabeth Prochaska, Chair of Birthrights and human rights barrister adds, “As Birthrights set out to the Review team in our ‘Right to Choice in Maternity Care’ submission, legal protections on existing rights to choice could be strengthened and clarified by the simple step of amending the NHS Constitution and the 2012 Regulations so that maternity services are included in the right to choose a provider in the same way that choice is guaranteed to recipients of other health services. This would give women the confidence that they were entitled to receive choice and oblige providers and commissioners to accept their responsibilities for providing it.

Birthrights welcomes the Review’s recommendation that the Department of Health establishes an insurance scheme to provide redress to parents whose babies have suffered harm during birth. Families would obtain financial support without having to prove that a professional was at fault during the birth, sparing them years of litigation and emotional trauma, and the NHS would be freed from the devastating consequences of a litigation culture which has spread fear and defensive practice.

The Review has provided a once in a lifetime opportunity to get maternity care right. We hope that the government seizes the chance.”

On 16th August the co-chairs of Birthrights and President of the Royal College of Midwives wrote to the members of the NHS England National Maternity Review. The letter (which was written in collaboration with and co-signed by senior lawyers, midwives, doctors and campaigners) asks that the Review makes the fundamental principles of respectful care and human rights a priority in its investigation of maternity services. We believe that safe maternity care is contingent on respectful care and that a rights-based approach offers the best means of improving maternity services in the UK.

A draft of the letter was presented and positively received at meeting with Baroness Cumberlege and Sir Cyril Chantler (who Chair and Vice-Chair the process respectively) earlier this summer. Now the group believe it is vital that all members of the Review process are aware that observing and building on human rights principles has the potential to transform maternity care.

We write to you as a group of health professionals, academics, campaigners and human rights lawyers who have a long-standing commitment to improving maternity care. As leaders in healthcare and human rights, we ask that the Review makes the fundamental principles of respectful care a priority in its investigation of maternity services. We believe that safe maternity care is contingent on respectful care and that a rights-based approach offers the best means of improving maternity services in the UK.

We outline the principles of respectful care and human rights below in the expectation that that they will inform the Review’s consultation process and discussion with stakeholders. We would be grateful for an opportunity to explore these issues with you in greater depth during the Review process.

Women’s fundamental human rights are at stake in maternity care

Pregnancy and childbirth are an intensely vulnerable time for women. Not only is the long-term physical health of women and babies at stake in the care they are given,women’s fundamental rights to human dignity and autonomy can be profoundly affected by their experience of maternity care.

The way a woman is treated during childbirth affects her at a time in her life when her identity as a mother is being forged. We know that many women experience anxiety,depression and post-traumatic stress disorder following childbirth and women with pre-existing mental health conditions may suffer a recurrence. Poor maternal mental health can affect the mother-child relationship and outcomes for children. Care providers have a critical role to play in ensuring that women emerge from childbirth physically and psychologically healthy and are able to develop a responsive and nurturing relationships with their children.

Dignity is the basis of respectful maternity care

Human dignity is the ultimate value on which respectful healthcare depends. It is most powerfully articulated in the imperative to treat a person as an end in their own right and not a means to an end. The relevance of this is clear in maternity care, when a woman risks being viewed as a means for the creation of life rather than as a person worthy of respect in herself. Dignity reinstates the woman as the central agent in childbirth. It means that her caregivers treat her as capable of making her own autonomous decisions about her child’s birth. Caregivers who protect women’s dignity listen to women and respect their perception of what it means for them to thrive as human beings.

Human rights law protects women’s health

The law protects people’s health by imposing obligations on governments and healthcare providers to respect human rights. Professional caregivers employed by NHS bodies are under a legal obligation to respect rights as set out in the European Convention on Human Rights. Article 2 of the Convention protects the right to life and requires the state to take positive action to ensure that critical healthcare services, including maternity care, are available to everyone.

Human rights do not stop at ensuring access to maternity services. The rights in the European Convention and under international treaties, including the Convention on the Elimination of Discrimination against Women and the Convention on Human Rights and Biomedicine, extend to protecting the way in which individuals are treated by their caregivers. These include the right not to be subjected to degrading treatment, the right to informed consent and the right to non-discrimination.

Healthcare professionals commonly consider the law to have a negative and distracting influence on care. The climate of litigation, particularly in maternity care, can make the law appear punitive. In fact, a human rights-based approach offers the potential for transformative impact on healthcare. The principles of dignity, autonomy and respect can create the foundation for a maternity service that is truly fit for purpose.

Human rights are an essential basis for safe health care

Respectful care is an essential component of safe care. Caregivers who listen to women, provide them with accurate information and respect their choices make a fundamental contribution to a safe maternity service. As the investigations into failing hospitals have repeatedly shown, lack of respect for patient dignity has gone hand in hand with clinical and systemic failings that have compromised patient safety.

The recent decision of the UK Supreme Court in Montgomery v Lanarkshire Health Board (2015) reveals the interdependence of safety and respectful care. Mrs Montgomery’s doctor treated her with condescension and withheld important information about the risks of vaginal birth for diabetic mothers. As a consequence, her right to make a safe choice was denied to her and her baby was damaged during birth. The Court found that clinicians must adopt a woman-centred approach to advice giving during pregnancy. It deprecated the use of consent forms and information leaflets and held that the law required clinicians to have detailed and personalised discussions with women that enabled them to make their own decisions on the basis of information about ‘all material risks’. The Court explained that it was necessary to impose legal obligations of this sort, so ‘that even those doctors who have less skill or inclination for communication, or who are more hurried, are obliged to pause and engage in the discussion which the law requires.’

The Montgomery decision has profound consequences for the interaction of the principle of informed consent, clinical practice and the structural implementation of choice in maternity services. If the Court’s judgment is to be upheld, professional carers must be given the time to discuss choices with women in their care and must respect the decisions that women choose to make.

At a global level, there is increasing awareness that protection of women’s human rights in maternity care offers the best chance for progress in maternity services. The recent Bohren systematic review on the mistreatment of women in health facilities provides powerful evidence that childbirth is a particularly vulnerable time for human rights abuses globally (that seemingly developed/ industrialised democracies and countries shouldn’t forget or need to continually guard against). As the WHO stated in 2014, ‘Rights-based approaches to organizing and managing health systems can facilitate the provision of respectful, quality care at birth.’3 In countries as diverse as Nigeria and Venezuela, which have legislated for human rights in maternity care,services are being configured with respectful care at their heart.

In the UK, in response to systemic failures, the NHS is increasingly using dignity principles not only to improve patient experience but as means to ensure patient safety. Queen’s Hospital Romford experienced a cluster of maternal deaths in 2011, blamed in part on poor culture and disrespectful behaviour amongst staff. The midwives acted to introduce mandatory respectful care training based on the White Ribbon Alliance Respectful Care Charter. It has had a measurable impact on the quality of care, reduced complaints, improved communication and staff behaviour. We believe that the response to the tragic failures at Morecambe Bay and elsewhere must put respect for women at its heart.

Safety can only be achieved by full recognition of women’s right to dignity and respect in maternity care. This entails much more than compliance with protocols or improved documentation; it means genuinely personalised care given by staff who listen to women and respect their individual needs.

Services built on human rights provide the best start in life

Human rights and high quality, safe maternity care are inseparable. The provision of maternity services that have the capability to provide appropriate, affordable, accessible and safe services that lead to the best start in life to all women and their babies require models and systems that provide care respectful to the dignity and autonomy of each woman and respond to individual and community needs.

The capability to provide respectful care that leads to healthy physical and psychological outcomes as well as supporting strong family relationships and reducing the impact of inequalities, requires structured development of culture and care pathways in models of care that meet each woman and baby’s health, personal and social needs and preferences.

This more personal and appropriate care should reduce variations in outcomes between services, while providing care that is tailored to each individual woman’s needs, values and preferences.

The ability of all carers to provide personalised care, supporting informed consent and offering genuine choices requires evidence-based information and information aids. All professionals must be able to convey information in an understandable way and work with the woman without prejudicing her decisions. This unified approach may be supported by human rights-based interdisciplinary education. It will also require that choices are available and visible. Time to talk and listen, not only to women but also to other professionals when consulting, referring and transferring care, is crucial.

Continuity of carer is the model of care that promotes human rights and a safe maternity service

Continuity of carer is the most appropriate means of enabling personalised care that respects women’s human rights. By developing services that ensure that every woman is cared for by named midwifery and medical staff, it is possible to create a relationships of trust that prevents fragmentation in care and reduces risk for women and babies. Continuity of carer is a critical part of a human rights based approach to maternity services because it enables respectful and safe care that is responsive to the woman and her family’s needs.

Preventive or public health approaches to reduce inequalities and the impact of social economic deprivation may be built in part by strengthening current community midwifery services, through the development of models of continuity of carer to provide more personal services, and integration of the pathway between primary care, social services and acute hospital based services.

What is quality and safety in maternity care?

The assessment of high quality, safe maternity care goes beyond measures of mortality or morbidity and encompasses multiple outcomes.For example, the most commonly used definition globally, and which is used by the WHO includes the
following dimensions: women’s experience and woman-centred care, effective, efficient, equitable, timely and safe care.

Using this definition, safer care is focused on services that do no harm to those who use or work in them, rather than just focusing on the potential risk that women or staff create.

This inclusive approach to safety encompasses a positive experience of care in which the woman is respected and listened to, secure relationships between woman and baby and within the family, the capacity to mother and care for the newborn and reduction in mental health problems. Healthy outcomes require respectful support for physiological processes, with medical intervention when needed or desired. The culture and systems of healthcare must ensure that women and their babies are given optimal chances of healthy outcomes without threat to their personal and legal
autonomy.

Conclusion

Respect for human rights is fundamental to all healthcare. It is particularly critical in maternity care, given the transformative nature of childbirth and the moral and legal imperative to respect the autonomy and dignity of women. Moreover, quality maternity care improves experiences for the woman and her family, and affects a baby’s start in life and subsequent life chances. Every mother and baby should have an equal access to quality care. We have described some principles that will enable professional carers to provide respectful, woman-centred, personalised care which, we argue, will contribute towards optimal physical and psychological outcomes and secure family relationships. Observing and building on human rights principles has the potential to transform maternity care.

We look forward to further discussion on this topic and thank you in advance for your time.

The Labour Party launched its Health Manifesto today. The announcement it chose to promote? A guarantee of personalised one-to-one care from a midwife for every woman during labour.

Here are the details from the Labour Party’s blog (strangely, the Health Manifesto itself doesn’t set this out):

One-to-one care means that a woman in established labour receives care from a designated midwife for the whole of that labour.

This means that a midwife will be able to care for mum 100 per cent of the time.

The one-to-one care will cover the labour, the birth and the period immediately after giving birth.

All the evidence shows this is the best way to improve the quality and safety of care for women and babies.

In fact NICE recently found that longer-term benefits of one-to-one may care include increased take-up of breastfeeding and a reduction in post-natal depression.

Currently, women giving birth in hospital may be attended by multiple midwives, depending on how long they are in labour. Shift changes are well-known to compromise women’s safety during childbirth and one-to-one care has repeatedly been shown to improve birth outcomes.

In February this year, NICE released its guideline on ‘Safe midwifery staffing for maternity settings’. It recommended one-to-one care for women in labour by a midwife, but it did not suggest that the women should receive care from the same midwife during labour.

The Labour pledge explicitly guarantees care in labour from a single designated midwife, so they have chosen to go further than the NICE recommendation. But they have not promised continuity of carer throughout pregnancy, labour and the post-natal period.

Milliband announced the pledge saying that he wanted every woman to receive ‘Call the Midwife’ style care. This is disingenuous: the wonder of the care provided by Jennifer Worth and the midwives of the 1950s was that the women received their antenatal care from the midwife who attended them in labour, giving them the chance to build a relationship over the course of pregnancy. If Labour’s pledge is honoured, women will not have met the midwife before their labour begins. While personalised one-to-one care during labour is certainly an improvement on the fractured care that women receive at present, the full benefits of personalised care will not be achieved by this election pledge.

Labour have suggested that the recruitment of 3,000 extra midwives will provide the staffing needed to make the pledge a reality. This might be optimistic. The RCM has said that there is currently a shortage of over 4,000 midwives and that’s without having to provide personalised support from a single midwife.

One-to-one support as envisioned by Labour would also have enormous consequences for shift patterns. There is no way for a hospital to guarantee that the same midwife would remain with a woman for her whole labour and maintain predictable shifts. Perhaps the only practical solution would be to introduce truly personalised care, so that midwives carried a caseload of women who they looked after during pregnancy and birth (as occurs now in Trusts that provide a dedicated home birth service).

It is not clear why the Labour Party did not promise real continuity of carer. It might well be more workable than the promise they chose to make instead.

A new report released this week by Doctors of the World has revealed the threat to the health of pregnant migrant women in the UK posed by NHS charging policies. The report found that two-thirds of pregnant users of the charity’s drop-in clinic in east London, who are mostly undocumented migrants or asylum seekers, had not received antenatal care until their second trimester. Half had no care for 20 weeks or longer. Nearly a third of women in the report were billed for their maternity care, one as much as £6,000.

‘These findings indicate an unacceptable inequality in our health system,’ Lucy Jones, an author of the study, says. ‘We must continue to improve access to healthcare for all mothers regardless of their wealth or immigration status.’ The average time the women in the report had been in the UK before becoming pregnant was longer than 5 years, debunking the myth of ‘health tourists’.

Maternity care in the UK is classified as ‘immediately necessary’ by the Department of Health and cannot be denied to any woman regardless of her means to pay for care. However, charges are imposed on those who are not ‘ordinarily resident’ in the UK and hospitals often pursue unpaid fees by means of debt collection. As the report states, NHS charges often deter vulnerable women from seeking care in pregnancy and can lead to undiagnosed health conditions and serious childbirth complications for woman and baby. One of the women in the report lost her premature baby after she did not access maternity care for 7 months.

In the past year, Birthrights has been receiving increasing numbers of enquiries from women who have been charged for the care. In many of these cases the charges have been levied unlawfully and contrary to government guidance. It appears that the funding crisis in the NHS and the focus on so-called ‘health tourism’ is leading to unjustified and oppressive charging decisions by NHS Trusts.

The Kirkup Report was published this week. It catalogues the failings in the maternity unit at Morecambe Bay between 2004-2013, when clinical errors contributed to the deaths of 3 mothers and 16 babies. As the Report acknowledges, healthcare professionals can be expected to make mistakes, but in Morecambe Bay, like Mid-Staffordshire and Queen’s Hospital Romford before it, those mistakes can be traced to a rotten institutional system that privileged its staff and reputation above the care of its patients.

Dr Kirkup makes clear his suspicion that many of the hospital’s failures are endemic in the NHS generally. The Report particularly criticises the ‘rudimentary and flawed’ investigations that took place after the deaths and suggests that investigative failures are widespread in NHS Trusts. Birthrights supports that view. Women who contact us frequently describe unsatisfactory hospital investigations into their complaints. We have heard of ‘investigations’ that do not interview relevant staff, that are hampered by missing or falsified notes and seem designed solely to protect the hospital’s interests. Women consistently report a refusal to acknowledge mistakes and a failure to treat them with compassion or respect. It is not only patients who suffer. Health professionals themselves can become the target. We have advised midwives going through punitive investigations (both by hospital management and Local Supervisory Authorities) that are used to silence them when they have raised concerns about culture and clinical standards.

Dr Kirkup singled out for blame a group of midwives who styled themselves ‘the musketeers’. They perpetuated a ‘them and us’ culture, dishonestly concealed mistakes and pursued ‘normal’ childbirth ‘at any cost’. The charge that midwives sacrificed safety to an ideological agenda is an interesting one. It has led to inevitable clamour in the right-wing press that midwives (the Daily Mail’s favourite witches) bully women into natural childbirth in spite of the risks. In fact, ‘normal’ childbirth is promoted by maternal healthcare organisations around the world because it has been shown repeatedly to lead to the healthiest outcomes for the large majority of mothers and babies. Normal birth is not championed by midwives because of medieval blood lust, but because it is usually the best means of ensuring that woman and baby emerge from labour in good health. The motivation for the Morecambe Bay midwives’ exclusion of obstetricians from the unit is unlikely to have been principled adherence to evidence-based care (‘musketeer’ would be an unusual choice of title for a natural birth advocate); rather, they appear to have initiated an unethical and toxic battle for professional control over decisions in the maternity unit that had fatal consequences for women and babies. It is a sad consequence that the pursuit of well-evidenced maternity care has been conflated with their impropriety.

As a consequence of the Kirkup Report, the Telegraph reports that the Department of Health has commissioned a review into the safety of midwife-led care (I cannot find any confirmation of this on the DoH website). The worth of such a review has to be questioned in light of the findings of the Birthplace Study, which comprehensively assessed the safety of midwife-led units in 2011, concluding that they led to better outcomes for women with low-risk pregnancies than other options. Rather than scapegoating a single profession, the Department of Health would do better to look at the systemic failures of communication and management that arose in all of the professions – midwifery, obstetrics, peadiatrics – implicated by the Report.

Kirkup analyses the failings at a single NHS Trust; it does not answer the enduring question that arises from every hospital scandal – how can those charged to protect health end up doing harm? But yet Kirkup’s conclusions hint at a fundamental unease in modern healthcare – is inhumane, and even fatal, treatment inherent in large-scale institutional care? Within his recommendations, Kirkup suggests that the opportunities afforded by smaller units with a high-level of personal responsibility have been overlooked. Morecambe Bay, Mid-Staffs and the inevitable scandals yet to unfold, ought to make us to ask: have our healthcare institutions become too big to protect the humans at their heart?